Personal Effects Signup Form

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Personal Details

Student's First Name *

Student's Last Name *

School / Yeshiva Name *

Passport Number *

Phone Number (in Israel) *

Email *

Address (in Israel) *

Period to be covered:

Start date of policy *

End date of policy *

Items to be Covered:

Cover: All contents are covered in the dorm / apartment for fire, water damage, theft and arson. (up to $20,000)
All Risks: Specified items (*) are covered both inside & outside the dorm / apartment up to policy limit ($4,000)

Total Sum Insured * $

All Risks total (*specified items) * $

Items:

Approx. Value $:

Clothing *

Books *

Musical Instruments

Other Items

* Photographic Equipment
- anything over $350

* Electronic Equipment
(stereo, laptop etc) - anything over $350

* Jewelry
- anything over $350

* Tefillin

All-Risk Cover Type * Up to $3000, cost: $80

Billing Details

Credit Card Type *

Credit Card Number *

Credit Card Expiration *

Card Owner *